Aldea R, Hazelton T, Hyder J, Kietrys D, Leary M; MPT Program jointly sponsored by Rutgers University Graduate School at Camden and UMDNJ, Stratford, NJ. kietrydm@umdnj.edu.

PURPOSE: This review evaluated randomized controlled trials (RCTs) published after 1994 regarding the efficacy of spinal manipulation for individuals with low back pain (LBP). METHODS: A database search for RCTs appearing in peer reviewed journals was conducted. Databases utilized were: Cinahl, OsteoMed, Cochrane, Medline, PubMed, and Healthstar/Ovid using the keywords: randomized controlled trials, manipulation, orthopedic or chiropractic manipulation, spinal manipulation, mobilization, acute onset, acute, subacute, or chronic low back pain, lumbar spine, LBP, classification, classification system, categorizing subgroups, and treatment. The RCTs were scored for quality according to criteria used in a similar review published in 1996. RESULTS: The search produced 9 RCTs. The average score for these RCTs was 63.2 (range 44-76) out of a possible 100 points. The results of the studies were mixed regarding the efficacy of spinal manipulation. Five of the 9 RCTs showed a positive effect of manipulation, while 4 of the 9 showed no significant difference. DISCUSSION: The mean score (63.2) of the 9 RCTs published since 1994, compared to the mean score (38.1) of RCTs included in the 1996 review, signifies improved research quality in recent years. Evidence regarding the efficacy of spinal manipulation as an intervention for patients with LBP remains inconclusive. However, studies showing a positive effect confirm the possibility that certain subgroups of patients may benefit from manipulation. There was a trend for RCTs to classify patients according to chronicity of symptoms. Results of RCTs suggest that there is a need for implementation of an alternative classification system. There are many different methods of classifying patients into subgroups (based on pathoanatomy, signs and symptoms, etc.) with little evidence currently available that shows which method is best. A recent publication suggests that implementation of a clinical decision making rule can greatly affect the likelihood of a positive response to manipulation. At the time of this review, no published RCTs have utilized a clinical decision making rule and most have not classified patients into subgroups that are more likely to experience a positive effect from manipulation. CONCLUSION: More RCTs are needed to determine the efficacy of spinal manipulation for patients with LBP. Future RCTs should implement classification schemes or clinical decision making rules to identify subgroups of patients most likely to benefit from manipulation. Such utilization may provide evidence that is supportive of manipulation. Research that validates classification schemes or clinical decision making rules is also needed. FUNDING SOURCE: None.

Copyright 2004 by the American Physical Therapy Association

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